电子病历系统应用的实践与探索

解放军总医院以建立完整的电子病历为目标,从电子病历的各个环节入手,全面进行电子病历系统建设.大力发展各类临床信息系统应用,实现了电子病历数据源的基本覆盖;以医生为中心,与大学联合研发了电子病历数据集成平台和一体化医护工作站,实现了电子病历数据集中管理和一体化综合展现;探索建立了代谢综合征临床知识库,实现了专科化的深层次临床辅助决策功能;利用电子病历开展合理用药监管、院内感染监测等多种面向实时医疗质量管理的应用,实现了信息可知、质量可控.

Practice and Exploration of Application of Electronic Medical Record System

PLA General Hospital taking the construction of complete electronic medical record as goal, sets up the electronic medical record system from all links in electronic medical record. It greatly develops the various clinical information system application, and reatizes the basic cover of data source of electronic medical record; taking doctors as the center and jointly with universities, it develops the data integration platform of electronic medical record and incorporative nursing workstation, and realizes the centralized management and the integrative as well as comprehensive exhibition of electronic medical record data; it builds up the clinical knowledgebase for metabolic syndrome by exploration, and realizes the specialized assistant decision-making function at the deep level; besides, it makes use of the electronic medical record to develop many applications, such as the rational drug administration and infectious monitor in hospital, to face the real-time medical quality management, and realizes the information knowability and quality controllability.